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Doyle MG, Chugunova M, Roche SL, Keener JP. Lumped parameter models for two-ventricle and healthy and failing extracardiac Fontan circulations. MATHEMATICAL MEDICINE AND BIOLOGY-A JOURNAL OF THE IMA 2021; 38:442-466. [PMID: 34534322 DOI: 10.1093/imammb/dqab012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 06/14/2021] [Accepted: 08/26/2021] [Indexed: 11/13/2022]
Abstract
Fontan circulations are surgical strategies to treat infants born with single ventricle physiology. Clinical and mathematical definitions of Fontan failure are lacking, and understanding is needed of parameters indicative of declining physiologies. Our objective is to develop lumped parameter models of two-ventricle and single-ventricle circulations. These models, their mathematical formulations and a proof of existence of periodic solutions are presented. Sensitivity analyses are performed to identify key parameters. Systemic venous and systolic left ventricular compliances and systemic capillary and pulmonary venous resistances are identified as key parameters. Our models serve as a framework to study the differences between two-ventricle and single-ventricle physiologies and healthy and failing Fontan circulations.
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Affiliation(s)
- Matthew G Doyle
- Department of Mechanical and Industrial Engineering and Division of Vascular Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Marina Chugunova
- Institute of Mathematical Sciences, Claremont Graduate University, Claremont, CA 91711, USA
| | - S Lucy Roche
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON M5S 1A1, Canada
| | - James P Keener
- Department of Mathematics, University of Utah, Salt Lake City, UT 84112, USA
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Hildebrand S, Groß-Hardt S, Schmitz-Rode T, Steinseifer U, Jansen SV. In-vitro performance of a single-chambered total artificial heart in a Fontan circulation. J Artif Organs 2021; 25:1-8. [PMID: 33956261 PMCID: PMC8866354 DOI: 10.1007/s10047-021-01273-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/26/2021] [Indexed: 11/28/2022]
Abstract
An in-vitro study was conducted to investigate the general feasibility of using only one pumping chamber of the SynCardia total artificial heart (TAH) as a replacement of the single ventricle palliated by Fontan circulation. A mock circulation loop was used to mimic a Fontan circulation. The combination of both ventricle sizes (50 and 70 cc) and driver (Freedom Driver and Companion C2 Driver) was investigated. Two clinical relevant scenarios (early Fontan; late Fontan) as derived from literature data were set up in the mock loop. The impact of increased transpulmonary pressure gradient, low atrial pressure, and raised central venous pressure on cardiac output was studied. From a hemodynamic point, the single-chambered TAH performed sufficiently in the setting of the Fontan circulation. Increased transpulmonary pressure gradient, from ideal to pulmonary hypertension, decreased the blood flow in combinations by almost 2 L/min. In the early Fontan scenario, a cardiac output of 3–3.5 L/min was achieved using the 50 cc ventricle, driven by the Companion C2 Driver. Even under pulmonary hypertension, cardiac outputs greater than 4 L/min could be obtained with the 70 cc pump chamber in the late Fontan scenario. In the clinically relevant Fontan scenarios, implementation of the single chambered TAH performed successfully from a hemodynamic point of view. The replacement of the failing univentricular heart by a single chamber of the SynCardia TAH may provide an alternative to a complex biventricular repair procedure or ventricular support in Fontan patients.
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Affiliation(s)
- Stephan Hildebrand
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, RWTH Aachen University, Pauwelsstraße 20, 52074, Aachen, Germany.
| | - Sascha Groß-Hardt
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, RWTH Aachen University, Pauwelsstraße 20, 52074, Aachen, Germany
| | - Thomas Schmitz-Rode
- Institute of Applied Medical Engineering, RWTH Aachen University, Aachen, Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, RWTH Aachen University, Pauwelsstraße 20, 52074, Aachen, Germany.
| | - Sebastian Victor Jansen
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, RWTH Aachen University, Pauwelsstraße 20, 52074, Aachen, Germany
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Systemic ventricular assist device support in Fontan patients: A report by ACTION. J Heart Lung Transplant 2021; 40:368-376. [DOI: 10.1016/j.healun.2021.01.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/03/2021] [Accepted: 01/13/2021] [Indexed: 12/31/2022] Open
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Farahmand M, Kavarana MN, Trusty PM, Kung EO. Target Flow-Pressure Operating Range for Designing a Failing Fontan Cavopulmonary Support Device. IEEE Trans Biomed Eng 2020; 67:2925-2933. [PMID: 32078526 DOI: 10.1109/tbme.2020.2974098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fontan operation as the current standard of care for the palliation of single ventricle defects results in significant late complications. Using a mechanical circulatory device for the right circulation to serve the function of the missing subpulmonary ventricle could potentially stabilize the failing Fontan circulation. This study aims to elucidate the hydraulic operating regions that should be targeted for designing cavopulmonary blood pumps. By integrating numerical analysis and available clinical information, the interaction of the cavopulmonary support via the IVC and full assist configurations with a wide range of simulated adult failing scenarios was investigated; with IVC and full assist corresponding to the inferior venous return or the entire venous return, respectively, being routed through the device. We identified the desired hydraulic operating regions for a cavopulmonary assist device by clustering all head pressures and corresponding pump flows that result in hemodynamic improvement for each simulated failing Fontan physiology. Results show that IVC support can produce beneficial hemodynamics in only a small fraction of failing Fontan scenarios. Cavopulmonary assist device could increase cardiac index by 35% and decrease the inferior vena cava pressure by 45% depending on the patient's pre-support hemodynamic state and surgical configuration of the cavopulmonary assist device (IVC or full support). The desired flow-pressure operating regions we identified can serve as the performance criteria for designing cavopulmonary assist devices as well as evaluating off-label use of commercially available left-side blood pumps for failing Fontan cavopulmonary support.
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Farahmand M, Kavarana MN, Kung EO. Risks and Benefits of Using a Commercially Available Ventricular Assist Device for Failing Fontan Cavopulmonary Support: A Modeling Investigation. IEEE Trans Biomed Eng 2020; 67:213-219. [PMID: 30998452 DOI: 10.1109/tbme.2019.2911470] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Fontan patients often develop circulatory failure and are in desperate need of a therapeutic solution. A blood pump surgically placed in the cavopulmonary pathway can substitute the function of the absent sub-pulmonary ventricle by generating a mild pressure boost. However, there is currently no commercially available device designed for the cavopulmonary application; and the risks and benefits of implanting a ventricular assist device (VAD), originally designed for the left ventricular application, on the right circulation of failing Fontan patients is not yet clear. Moreover, further research is needed to compare the hemodynamics between the two clinically-considered surgical configurations for cavopulmonary assist, with Full and inferior vena cava (IVC) support corresponding to the entire venous return or only the inferior venous return, respectively, being routed through the VAD. In this study, we used a numerical model of the failing Fontan physiology to evaluate the Fontan hemodynamic response to a left VAD during the IVC and Full support scenarios. We observed that during Full support, the VAD improved the cardiac output while maintaining blood pressures within safe ranges, and lowered the IVC pressure to <15 mmHg; however, we found a potential risk of lung damage at higher pump speeds due to the excessive pulmonary pressure elevation. IVC support, on the other hand, did not benefit the hemodynamics in the patient cases simulated, resulting in the superior vena cava pressure increasing to an unsafe level of >20 mmHg. The findings in this study may be helpful to surgeons for recognizing the risks of a cavopulmonary VAD and developing coherent clinical strategies for the implementation of cavopulmonary support.
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Broda CR, Taylor DA, Adachi I. Progress in experimental and clinical subpulmonary assistance for Fontan circulation. J Thorac Cardiovasc Surg 2018; 156:1949-1956. [PMID: 29884497 DOI: 10.1016/j.jtcvs.2018.04.102] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/09/2018] [Accepted: 04/24/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Christopher R Broda
- Department of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Tex.
| | - Doris A Taylor
- Regenerative Medicine Research, Texas Heart Institute, Houston, Tex
| | - Iki Adachi
- Department of Congenital Heart Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Tex
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Granegger M, Schweiger M, Schmid Daners M, Meboldt M, Hübler M. Cavopulmonary mechanical circulatory support in Fontan patients and the need for physiologic control: A computational study with a closed-loop exercise model. Int J Artif Organs 2018. [DOI: 10.1177/0391398818762359] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: Rotary blood pumps are a promising treatment approach for patients with a total cavopulmonary connection and a failing cardiovascular system. The aim of this study was to investigate the hemodynamic effects of cavopulmonary support using a numerical model with closed-loop baroreflex and exercise mechanisms. Methods: A numerical model of the univentricular cardiovascular system was developed, mimicking the hemodynamics during rest and exercise. Rotary blood pumps with different hydraulic pump characteristics (flat vs steep pressure-flow relationships) were investigated in the cavopulmonary position. Furthermore, two support modes—a constant speed setting and a physiologically controlled speed—were examined. Results: Hemodynamics without rotary blood pumps were achieved with less than 10% deviation from reported values during rest and exercise. Rotary blood pumps at constant speed improve the hemodynamics at rest, however, they constitute a hydraulic resistance during light (steep characteristics) or moderate (flat characteristics) exercise. In contrast, physiologic control increases cardiac output (moderate exercise: 8.2 vs 7.4 L/min) and reduces sympathetic activation (heart rate at moderate exercise: 111 vs 123 bpm). Conclusion: In this simulation study, the necessity of an automatically controlled rotary blood pump in the cavopulmonary position was shown. A pump at constant speed might constitute an additional resistance to venous return during physical activity. Therefore, a physiologic control algorithm based on the pressure difference between the caval veins and the atrial pressure is proposed to improve hemodynamics, especially during physical activity.
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Affiliation(s)
- Marcus Granegger
- Pediatric Heart Center, University Children’s Hospital, University of Zurich, Zurich, Switzerland
| | - Martin Schweiger
- Pediatric Heart Center, University Children’s Hospital, University of Zurich, Zurich, Switzerland
| | - Marianne Schmid Daners
- pd
- z Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Mirko Meboldt
- pd
- z Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Michael Hübler
- Pediatric Heart Center, University Children’s Hospital, University of Zurich, Zurich, Switzerland
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Concomitant Pulsatile and Continuous Flow VAD in Biventricular and Univentricular Physiology: A Comparison Study with a Numerical Model. Int J Artif Organs 2017; 40:74-81. [DOI: 10.5301/ijao.5000562] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2017] [Indexed: 11/20/2022]
Abstract
Introduction To develop and test a lumped parameter model to simulate and compare the effects of the simultaneous use of continuous flow (CF) and pulsatile flow (PF) ventricular assist devices (VADs) to assist biventricular circulation vs. single ventricle circulation in pediatrics. Methods Baseline data of 5 patients with biventricular circulation eligible for LVAD and of 5 patients with Fontan physiology were retrospectively collected and used to simulate patient baselines. Then, for each patient the following simulations were performed: (a) CF VAD to assist the left ventricle (single ventricle) + a PF VAD to assist the right ventricle (cavo-pulmonary connection) (LCF + RPF); (b) PF VAD to assist the left ventricle (single ventricle) + a CF VAD to assist the right ventricle (cavo-pulmonary connection) (RCF + LPF) Results In biventricular circulation, the following results were found: cardiac output (17% RCF + LPF, 21% LCF + RPF), artero-ventricular coupling (-36% for the left ventricle and -21.6% for the right ventricle), pulsatility index (+6.4% RCF + LPF, p = 0.02; -8.5% LCF + RPF, p = 0.00009). Right (left) atrial pressure and right (left) ventricular volumes are decreased by the RCF + LPF (by RPF + LCF). Pulmonary arterial pressure decreases in the LCF + RPF configuration. In Fontan physiology: cardiac output (LCF + RPF 35% vs. 8% in RCF + LPF), ventricular preload (+4% RCF + LPF, -10% LCF + RPF), Fontan conduit pressure (-5% RCF + LPF, +7% LCF + RPF), artero-ventricular coupling (-14% RCF + LPF vs. -41% LCF + RPF) and pulsatility (+13% RCF + LPF, - 8% LCF + RPF). Conclusions A numerical model supports clinicians in defining and innovating the VAD implantation strategy to maximize the hemodynamic benefits. Results suggest that the hemodynamic benefits are maximized by the LCF + RPF configuration.
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Villa CR, Morales DLS. The Total Artificial Heart in End-Stage Congenital Heart Disease. Front Physiol 2017; 8:131. [PMID: 28536530 PMCID: PMC5422510 DOI: 10.3389/fphys.2017.00131] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 02/21/2017] [Indexed: 11/13/2022] Open
Abstract
The development of durable ventricular assist devices (VADs) has improved mortality rates and quality of life in patients with end stage heart failure. While the use of VADs has increased dramatically in recent years, there is limited experience with VAD implantation in patients with complex congenital heart disease (CHD), despite the fact that the number of patients with end stage CHD has grown due to improvements in surgical and medical care. VAD use has been limited in patients with CHD and end stage heart failure due to anatomic (systemic right ventricle, single ventricle, surgically altered anatomy, valve dysfunction, etc.) and physiologic constraints (diastolic dysfunction). The total artificial heart (TAH), which has right and left sided pumps that can be arranged in a variety of orientations, can accommodate the anatomic variation present in CHD patients. This review provides an overview of the potential use of the TAH in patients with CHD.
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Affiliation(s)
- Chet R Villa
- Cincinnati Children's Hospital Medical Center, Heart InstituteCincinnati, OH, USA
| | - David L S Morales
- Cincinnati Children's Hospital Medical Center, Heart InstituteCincinnati, OH, USA
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Di Molfetta A, Ferrari G, Iacobelli R, Filippelli S, Amodeo A. Concurrent use of continuous and pulsatile flow Ventricular Assist Device on a fontan patient: A simulation study. Artif Organs 2016; 41:32-39. [PMID: 28025826 DOI: 10.1111/aor.12859] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/07/2016] [Accepted: 08/18/2016] [Indexed: 01/15/2023]
Abstract
The aim of this work is to develop and test a lumped parameter model of the cardiovascular system to simulate the concurrent use of pulsatile (PVAD) and continuous flow (CVAD) ventricular assist device (VAD) on Fontan patients. Echocardiographic and hemodynamic data of five Fontan patients were retrospectively collected and used to simulate the patients' baseline hemodynamics. Then, for each patient, the following assistance modality was simulated for the cavopulmonary and the single ventricle (SV): (a) CVAD for cavopulmonary assistance (RCF) and PVAD assisting the SV (LCF) (RPF + LCF), (b) CVAD assisting SV and PVAD for cavopulmonary assistance (LPF + RCF). The numerical model can well reproduce patients' baseline. The cardiac output increases more importantly in the LCF + RPF configuration (35 vs. 8%). Ventricular volume decreases more evidently in the configuration LCF + RPF (28 vs. 6%), atrial pressure decreases in the LCF + RPF modality (10%), while it slightly increases in the RCF + LPF modality. The pulmonary arterial pressure slightly decreases (increases) in the configuration RCF + LPF (LCF + RPF). Ventricular external work increases in both configurations because of the total increment of the cardiac output. However, artero-ventricular coupling improves in both configurations: RCF + LPF-14%, LCF + RPF-41%. The pulsatility index decreases (increases) by 8% (13.8%) in the configuration LCF + RPF (RCF + LPF). A model could permit us to simulate extreme physiological conditions of the implantation of both CF and PF VAD on the Fontan patient and could permit to choose the proper VAD on the base of patients' condition. The configuration LCF + RPF seems to maximize the hemodynamic benefits.
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Affiliation(s)
- Arianna Di Molfetta
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù
| | | | - Roberta Iacobelli
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù
| | - Sergio Filippelli
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù
| | - Antonio Amodeo
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù
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Abstract
In this Editor's Review, articles published in 2015 are organized by category and briefly summarized. We aim to provide a brief reflection of the currently available worldwide knowledge that is intended to advance and better human life while providing insight for continued application of technologies and methods of organ Replacement, Recovery, and Regeneration. As the official journal of The International Federation for Artificial Organs, The International Faculty for Artificial Organs, the International Society for Rotary Blood Pumps, the International Society for Pediatric Mechanical Cardiopulmonary Support, and the Vienna International Workshop on Functional Electrical Stimulation, Artificial Organs continues in the original mission of its founders "to foster communications in the field of artificial organs on an international level." Artificial Organs continues to publish developments and clinical applications of artificial organ technologies in this broad and expanding field of organ Replacement, Recovery, and Regeneration from all over the world. We take this time also to express our gratitude to our authors for providing their work to this journal. We offer our very special thanks to our reviewers who give so generously of their time and expertise to review, critique, and especially provide meaningful suggestions to the author's work whether eventually accepted or rejected. Without these excellent and dedicated reviewers, the quality expected from such a journal could not be possible. We also express our special thanks to our Publisher, John Wiley & Sons for their expert attention and support in the production and marketing of Artificial Organs. We look forward to reporting further advances in the coming years.
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Gerardin J, Rodriguez F, Saraf A, Book WM. Heart transplantation in adults for Fontan failure. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Di Molfetta A, Ferrari G, Iacobelli R, Fresiello L, Pilati M, Toscano A, Filippelli S, Morelli S, Amodeo A. Acute Biventricular Interaction in Pediatric Patients Implanted with Continuous Flow and Pulsatile Flow LVAD: A Simulation Study. ASAIO J 2016; 62:591-9. [DOI: 10.1097/mat.0000000000000396] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Shimizu S, Kawada T, Une D, Fukumitsu M, Turner MJ, Kamiya A, Shishido T, Sugimachi M. Partial cavopulmonary assist from the inferior vena cava to the pulmonary artery improves hemodynamics in failing Fontan circulation: a theoretical analysis. J Physiol Sci 2016; 66:249-55. [PMID: 26546008 PMCID: PMC10717700 DOI: 10.1007/s12576-015-0422-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 10/23/2015] [Indexed: 11/28/2022]
Abstract
Cavopulmonary assist (CPA) for failing Fontan patients remains a challenging issue in the clinical setting. To evaluate the effectiveness of a partial CPA from the inferior vena cava (IVC) to the pulmonary artery (PA), we performed a theoretical analysis using a computational model of the Fontan circulation. Cardiac chambers and vascular systems were described as the time-varying elastance model and the modified three-element Windkessel model, respectively. A rotational pump described as a non-linear function was inserted between the IVC and the PA. When pulmonary vascular resistance index varied from 2.1 to 5.9 Wood units m(2), the partial CPA maintained cardiac index as efficiently as total CPA and markedly reduced the IVC pressure compared with total CPA. However, the partial CPA increased the superior vena cava pressure substantially. The modification from total to partial CPA is potentially an effective alternative in failing Fontan patients suffering from high IVC pressure.
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Affiliation(s)
- Shuji Shimizu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan.
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Dai Une
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Masafumi Fukumitsu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Michael James Turner
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Atsunori Kamiya
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Toshiaki Shishido
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan
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Abstract
Early survival after the Fontan operation has improved significantly leading to a lifetime of Fontan circulation for patients. There is a natural progression of pulmonary artery pressure during the human lifetime that is easily tolerated in two-ventricle physiology but is deleterious for single-ventricle physiology. Obstructions in the venous to pulmonary artery pathway and pulmonary venous return or ventricular outflow, atrioventricular valve dysfunction (regurgitation), pulmonary arteriovenous malformations, venous thrombosis, and the development of atrial arrhythmias can lead to reduced functional status. These complications have been demonstrated in older patients with largely atriopulmonary connections owing to time accrual and unfavorable flow characteristics. Various surgical and catheter interventions aimed at reducing morbidity and mortality have been attempted to treat these identifiable abnormalities. The purpose of this article is to review the extant literature on Fontan Conversion and to assess the lessons learned over 20 years.
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Affiliation(s)
- Constantine Mavroudis
- Johns Hopkins Children’s Heart Surgery, Florida Hospital for Children, Johns Hopkins University School of Medicine, Orlando, FL, USA
| | - Barbara J. Deal
- Division of Pediatric Cardiology, Department of Pediatrics, Ann & Robert H Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Simulation of Acute Haemodynamic Outcomes of the Surgical Strategies for the Right Ventricular Failure Treatment in Pediatric LVAD. Int J Artif Organs 2016; 38:638-45. [DOI: 10.5301/ijao.5000462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2016] [Indexed: 11/20/2022]
Abstract
Background Right ventricular failure (RVF) is one of the major complications during LVAD. Apart from drug therapy, the most reliable option is the implantation of RVAD. However, BIVAD have a poor prognosis and increased complications. Experiments have been conducted on alternative approaches, such as the creation of an atrial septal defect (ASD), a cavo-aortic shunt (CAS) including the LVAD and a cavo-pulmonary connection (CPC). This work aims at realizing a lumped parameter model (LPM) to compare the acute hemodynamic effects of ASD, CPC, CAS, RVAD in LVAD pediatric patients with RVF. Methods Data of 5 pediatric patients undergoing LVAD were retrospectively collected to reproduce patients baseline hemodynamics with the LPM. The effects of continuous flow LVAD implantation complicated by RVF was simulated and then the effects of ASD, CPC, CAS and RVAD treatments were simulated for each patient. Results The model successfully reproduced patients' baseline and the hemodynamic effects of the surgical strategies. Simulating the different surgical strategies, an unloading of the right ventricle and an increment of left ventricular preload were observed with an improvement of the hemodynamics (total cardiac output: ASD +15%, CPC +10%, CAS +70% RVAD +20%; right ventricular external work: ASD -19%, CPC -46%, CAS -76%, RVAD -32%; left ventricular external work: ASD +12%, CPC +28%, RVAD +64%). Conclusions The use of numerical model could offer an additional support for clinical decision-making, also potentially reducing animal experiments, to compare the outcome of different surgical strategies to treat RVF in LVAD.
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Di Molfetta A, Amodeo A, Fresiello L, Filippelli S, Pilati M, Iacobelli R, Adorisio R, Colella D, Ferrari G. The use of a numerical model to simulate the cavo-pulmonary assistance in Fontan circulation: a preliminary verification. J Artif Organs 2015; 19:105-13. [PMID: 26545595 DOI: 10.1007/s10047-015-0874-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 10/26/2015] [Indexed: 12/30/2022]
Abstract
The lack of an established experience on the use of VAD for the cavo-pulmonary assistance leads to the need of dedicated VADs development and animal experiments. A dedicated numerical model could support clinical and experimental strategies design and new VADs testing. The aim of this work is to perform a preliminary verification of a lumped parameter model of the cardiovascular system to simulate Fontan physiology and the effect of cavo-pulmonary assistance. Literature data of 4 pigs were used to simulate animals' baseline, and then the model was tested in simulating Fontan circulation and cavo-pulmonary-assisted condition comparing the simulation outcome (Sim) with measured literature data (Me). The results show that the numerical model can well reproduce experimental data in all three conditions (baseline, Fontan and assisted Fontan) [cardiac output (l/min): Me = 2.8 ± 1.7, Sim = 2.8 ± 1.8; ejection fraction (%): Me = 57 ± 17, Sim = 54 ± 17; arterial systemic pressure (mmHg): Me = 41.8 ± 18.6, Sim = 43.8 ± 18.1; pulmonary arterial pressure (mmHg): Me = 15.4 ± 8.9, Sim = 17.7 ± 9.9; caval pressure (mmHg): Me = 6.8 ± 4.1, Sim = 7 ± 4.6]. Systolic elastance, arterial systemic and arterial pulmonary resistances increase (10, 69, and 100 %) passing from the biventricular circulation to the Fontan physiology and then decrease (21, 39, and 50 %) once the VAD was implanted. The ventricular external work decreases (71 %) passing from the biventricular circulation to the Fontan physiology and it increases three times after the VAD implantation in parallel with the VAD power consumption. A numerical model could support clinicians in an innovative and challenging field as the use of VAD to assist the Fontan physiology and it could be helpful to personalize the VAD insertion on the base of ventricular systo-diastolic function, circulatory parameters and energetic variables.
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Affiliation(s)
- Arianna Di Molfetta
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Via San Martino della Battaglia, 44, 00185, Rome, Italy.
| | - Antonio Amodeo
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Via San Martino della Battaglia, 44, 00185, Rome, Italy
| | | | - Sergio Filippelli
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Via San Martino della Battaglia, 44, 00185, Rome, Italy
| | - Mara Pilati
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Via San Martino della Battaglia, 44, 00185, Rome, Italy
| | - Roberta Iacobelli
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Via San Martino della Battaglia, 44, 00185, Rome, Italy
| | - Rachele Adorisio
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Via San Martino della Battaglia, 44, 00185, Rome, Italy
| | - Dionisio Colella
- Cardiac Surgery Intensive Care Unit, University of Tor Vergata, Rome, Italy
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18
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Di Molfetta A, Amodeo A, Gagliardi MG, Trivella MG, Fresiello L, Filippelli S, Toscano A, Ferrari G. Hemodynamic Effects of Ventricular Assist Device Implantation on Norwood, Glenn, and Fontan Circulation: A Simulation Study. Artif Organs 2015; 40:34-42. [PMID: 26526959 DOI: 10.1111/aor.12591] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The growing population of failing single-ventricle (SV) patients might benefit from ventricular assist device (VAD) support as a bridge to heart transplantation. However, the documented experience is limited to isolated case reports. Considering the complex and different physiopathology of Norwood, Glenn, and Fontan patients and the lack of established experience, the aim of this work is to realize and test a lumped parameter model of the cardiovascular system able to simulate SV hemodynamics and VAD implantation effects to support clinical decision. Hemodynamic and echocardiographic data of 30 SV patients (10 Norwood, 10 Glenn, and 10 Fontan) were retrospectively collected and used to simulate patients' baseline. Then, the effects of VAD implantation were simulated. Simulation results suggest that the implantation of VAD: (i) increases the cardiac output and the mean arterial systemic pressure in all the three palliation conditions (Norwood 77.2 and 19.7%, Glenn 38.6 and 32.2%, and Fontan 17.2 and 14.2%); (ii) decreases the SV external work (Norwood 55%, Glenn 35.6%, and Fontan 41%); (iii) decreases the pressure pulsatility index (Norwood 65.2%, Glenn 81.3%, and Fontan 64.8%); (iv) increases the pulmonary arterial pressure in particular in the Norwood circulation (Norwood 39.7%, Glenn 12.1% and Fontan 3%); and (v) decreases the atrial pressure (Norwood 2%, Glenn 10.6%, and Fontan 8.6%). Finally, the VAD work is lower in the Norwood circulation (30.4 mL·mm Hg) in comparison with Fontan (40.3 mL·mm Hg) and to Glenn (64.5 mL·mm Hg) circulations. The use of VAD in SV physiology could be helpful to bridge patients to heart transplantations by increasing the CO and unloading the SV with a decrement of the atrial pressure and the SV external work. The regulation of the pulmonary flow is challenging because the Pap is increased by the presence of VAD. The hemodynamic changes are different in the different SV palliation step. The use of numerical models could be helpful to support patient and VAD selection to optimize the clinical outcome.
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Affiliation(s)
- Arianna Di Molfetta
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Antonio Amodeo
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Maria G Gagliardi
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Maria G Trivella
- Cardiovascular Engineering Laboratory-Institute of Clinical Physiology, CNR, Rome, Italy
| | - Libera Fresiello
- Clinical Cardiac Surgery Department, Catholic University of Leuven, Leuven, Belgium
| | - Sergio Filippelli
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Alessandra Toscano
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Gianfranco Ferrari
- Cardiovascular Engineering Laboratory-Institute of Clinical Physiology, CNR, Rome, Italy
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19
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Di Molfetta A, Ferrari G, Filippelli S, Fresiello L, Iacobelli R, Gagliardi MG, Amodeo A. Use of Ventricular Assist Device in Univentricular Physiology: The Role of Lumped Parameter Models. Artif Organs 2015; 40:444-53. [PMID: 26494529 DOI: 10.1111/aor.12583] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Failing single-ventricle (SV) patients might benefit from ventricular assist devices (VADs) as a bridge to heart transplantation. Considering the complex physiopathology of SV patients and the lack of established experience, the aim of this work was to realize and test a lumped parameter model of the cardiovascular system, able to simulate SV hemodynamics and VAD implantation effects. Data of 30 SV patients (10 Norwood, 10 Glenn, and 10 Fontan) were retrospectively collected and used to simulate patients' baseline. Then, the effects of VAD implantation were simulated. Additionally, both the effects of ventricular assistance and cavopulmonary assistance were simulated in different pathologic conditions on Fontan patients, including systolic dysfunction, diastolic dysfunction, and pulmonary vascular resistance increment. The model can reproduce patients' baseline well. Simulation results suggest that the implantation of VAD: (i) increases the cardiac output (CO) in all the three palliation conditions (Norwood 77.2%, Glenn 38.6%, and Fontan 17.2%); (ii) decreases the SV external work (SVEW) (Norwood 55%, Glenn 35.6%, and Fontan 41%); (iii) increases the mean pulmonary arterial pressure (Pap) (Norwood 39.7%, Glenn 12.1%, and Fontan 3%). In Fontan circulation, with systolic dysfunction, the left VAD (LVAD) increases CO (35%), while the right VAD (RVAD) determines a decrement of inferior vena cava pressure (Pvci) (39%) with 34% increment of CO. With diastolic dysfunction, the LVAD increases CO (42%) and the RVAD decreases the Pvci. With pulmonary vascular resistance increment, the RVAD allows the highest CO (50%) increment with the highest decrement of Pvci (53%). The single ventricular external work (SVEW) increases (decreases) increasing the VAD speed in cavopulmonary (ventricular) assistance. Numeric models could be helpful in this challenging and innovative field to support patients and VAD selection to optimize the clinical outcome and personalize the therapy.
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Affiliation(s)
- Arianna Di Molfetta
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Rome, Italy
| | | | - Sergio Filippelli
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Libera Fresiello
- Section of Rome, CNR, Institute of Clinical Physiology, Rome, Italy
| | - Roberta Iacobelli
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Maria G Gagliardi
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Antonio Amodeo
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Rome, Italy
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20
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A cardiovascular simulator tailored for training and clinical uses. J Biomed Inform 2015; 57:100-12. [DOI: 10.1016/j.jbi.2015.07.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 06/10/2015] [Accepted: 07/06/2015] [Indexed: 11/20/2022]
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